Client Information Form
Welcome to Colquitt Animal Hospital!
I am at least 18 years of age and the legal owner of this animal.
Current Mailing Address
Street Address Line 2
State / Province
Postal / Zip Code
Main Phone (Best way to contact your for text alerts and reminders)
Additional Phone Number
I give consent for my pet to be photographed, and that my pet's name and photograph can be used for any lawful purposes. I hereby authorize Colquitt Animal Hospital to edit, alter, copy, exhibit, publish or distribute these photos for educational or promotional purposes. In addition, I waive any rights or royalties related to the use of any photographs.
I do not consent
For your convenience, at the time we perform services, we accept Visa, Mastercard, Discover, American Express as well as cash or check. Please indicate your method of payment:
Up to 3 held checks
I would like estimates before services are performed
I hereby authorize the veterinarian to prescribe for, or treat, the below pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of discharge and that a deposit may be required for surgical treatment.
Date of Birth (if known)
Has your pet ever bitten before? Our team is trained on handling aggressive dogs, we just need to know so we can be prepared for the special handling your pet may need.
My pet usually tolerates new people and situations very well.
My pet is has showed aggression, but never bitten: use caution
Yes, my pet has bitten before he/she may need a muzzle
My pet has shown extreme aggression. He/she may require sedation.
Does your pet have any allergies or preexisting conditions we should be aware of? If yes, please explain:
Has your pet ever had a reaction to vaccines or medications? If yes, please explain:
Please list below the names of your other current household pets that have been seen under our care. We will inactivate your previous pets that are not listed to keep your records up to date.
Should be Empty: